Two Treatment Plans

lexni

Hello,

I was diagnosed with IDC in my left breast. I have a 1.8cm tumor, HER2+. ER/PR-, Grade 3 tumor, 50% KI-67 rating. I have the PAL2B mutation so I am planning on doing a b/l mastectomy. I've had two opinions (at Swedish Cancer Institute and the Seattle Cancer Care Alliance) and they proposed two very different treatment plans. I'm having a very difficult time figuring out what the right course is.

Treatment Plan #1 - Predjuvant chemo of Taxol, Carbo, Herceptin, and Perjeta for 12 weeks. At the conclusion of the chemo, imaging to see what tumor looks like. If it responds, then surgery. FEC treatment post surgery if necessary. Completion of 12 mos herceptin. (This plan is based on the Tryphaena study or at least the results of said study). The goal here is to reach pCR before surgery, which I understand to be helpful to ensure that the chemo is effective with my cancer.

Treatment Plan #2 - No preadjuvant treatment. Surgery, then 12 weeks of chemo on the APT regimen, including Herceptin for 12 mos post surgery. This is based on the most recent study released at ASCO under the APHINITY study (which showed little improvement in outcome with Perjeta.) This team felt that the above treatment plan was over treatment and not necessary for the size of my tumor and the fact that my MRI does not show any other cancer. The benefit here is that surgery will show if it is in my nodes or hiding elsewhere to tailor treatment to it after surgery.

How did you decide what treatment to do? Any thoughts on surgery versus chemo first? I truly don't know how to make the decision.

Thanks

ElaineTherese

Hi!

I also had HER2+ cancer, but did a different regimen. (What is the APT regimen?) I went the neoadjuvant route, with four doses of Adriamycin + Cytoxan every two weeks and then 12 Taxols, with Herceptin and Perjeta. That chemo wiped out the active cancer in my breast and compromised node, so I ended up doing a lumpectomy. Then, it was on to radiation and a year of Herceptin alone.

The advantages of neoadjuvant treatment are 1) you can see whether or not chemo worked for your particular cancer; and 2) you may be able to expand your surgical options (in my case, doing a lumpectomy rather than a mastectomy). For me, doing a lumpectomy was preferable because I didn't want to do reconstruction (can involve multiple surgeries).

Since you have the PALB2B mutation, you may not care about expanding your surgical options (bilateral mastectomy might be the way to go no matter what). So, the only advantage for you of neoadjuvant treatment would be seeing whether or not chemo worked for you.

Have you had a PET scan? Sometimes that picks up more things than the MRI.

Your tumor size is almost 2 cm., so it's a squishy area. If it were 2 cm. or larger, national guidelines would recommend Perjeta for you. But, it is true that Perjeta is typically not offered for lumps smaller than 2 cm.

Good luck!

lexni

Thanks Elaine! APT is Adjuvant Paclitaxel and Trastuzumab, which seems to also be referred to as the Dana Farber regimen.

I agree I'm in this strange area of almost 2cm; it seems like one set of doctors is rounding down while the other is rounding up.

Thank you for sharing!

MinusTwo

lexni - I would definitely do neo-adjuvant chemo. Herceptin has made this a game changer. I had TCHP but decided not to continue with the Perjeta for the rest of the year on Herceptin.

I could be wrong, but I have some question about whether Affinity was testing Perjeta for a year and not the neo-adjuvant 6 rounds. TCHP has been standard of care for some time now with neo-adjuvant.

ElaineTherese

Oh! APT is just adjuvant Taxol + Herceptin. Taxol is the milder cousin of Taxotere, which is usually the taxane in TCHP. I had TH -- it gave me mild diarrhea and some fatigue; it wasn't that bad, for me anyways.

Yes, Option #1 is definitely more aggressive than Option #2. My only thought is that with ER-/PR-, chemo and targeted therapy are the only systemic options available. I think that ER-/PR-/HER2+ has slightly higher recurrence rates than triple positive (ER+/PR+/HER2+), which is what I have. I guess I'd go with the more aggressive chemo combo because you can't take hormonal therapy as a preventive measure.

Good luck, whatever you decide.

MinusTwo

I agree Elaine. Since I'm ER/PR negative, the only good news I had was HER2+. So I threw the kitchen sink at it.

Tara17

lexni -- when i asked my doctor about neoadjuvant treatment, she said that the only purpose of neoadjuvant was to render a larger tumor smaller ( so creating the ability to do a lumpectomy instead of a mastectomy ) . Pathological CR was used in the clinical trials as a surrogate marker for assessing the regimen but clinically she said that the most important first step is to get the tumor out . The node status was the most important intial feature to be able to stage . With negative nodes you woudl be a stage 1, and the APT regimen would make sense. With positive nodes, then the more intense regimen would make better sense. This was my understanding for my options at the time of my diagnosis .what have your doctors stated about when your nodes will be tested to fully understand your stage ?

So i went with lumpectomy and sentinel node first --the sentinel node allowed full staging and then based on this, the oncologist decided the regimen. I got the APT regimen

Anyway ,just sharing my experience . These are tough decisions and I wish you the best .

I wish you good luck with whatever path you choose!

Momine

I am guessing that the more aggressive approach is based on the grade 3 and high Ki-67. I had neo-adjuvant chemo. There was no chance of my having a lumpectomy, so that was not the purpose. The purpose was two-fold: to be able to check that the chemo did something and to stop any wandering cancer cells before they decided to metastasize. My docs felt that chemo was more urgent than surgery, basically. They were concerned that if I had any complications from surgery, the chemo might be dangerously delayed.

Kimm992

Tara...my oncologist and surgeon knew from the start that I was going to need a mastectomy but they STILL agreed that neoadjuvent chemo was the way to go. My onc's explanation of this was that HER2+ is very aggressive and that if there were microscopic cancer cells floating around in my body we wanted to STOP them immediately before they had a chance to grow in distant places and become stage 4.

Waiting for surgery, having surgery, recovering...if there's a possible infection then you have to wait even longer...would mean that I could have been 2+ months before I started chemo. That is 2 months that those cancer cells would have had to float around my body and potentially start growing in my liver, lungs, wherever.

He didn't want to take any chances and I agreed.

lexni

Thank you everyone. So hard to know what the right decision is but I appreciate you sharing your experiences.

cndble

I can't speak specifically to which treatment plan you should choose, but I will say I am in Seattle and chose Swedish over SCCA hands down. It didn't seem like the team at SCCA had a plan at all and argued in front of me about recommended treatment. Swedish has been wonderful.

Moderators

Dear cndble,

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Momine

Kimm, same story for me.